PEASD ATI FORM C GRADED A VERY IMPORTANT RESOURCE FOR EXAM GUIDE

Form C 1. A nurse is caring for a child during a tonic-clonic seizure. Which of the following actions should the nurse take? ( select all that apply) A. Clear the area of hard objects. B. Firmly hold the child’s arms ...

Form C 1. A nurse is caring for a child during a tonic-clonic seizure. Which of the following actions should the nurse take? ( select all that apply) A. Clear the area of hard objects. B. Firmly hold the child’s arms to one side. C. Place a pillow under the child’s head. D. Insert a tongue blade into the child’s mouth. E. Loosen tight clothing around the child’s neck 2. A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which of the following restraints should the nurse plan to use for this procedure? A. Elbow B. Mitten C. Jacket D. Mummy 3. A nurse is teaching a parent of a preschool-age child about management of sleep terrors. Which of the following instructions should the nurse include? A. Take the child to the parent’s bed to resume sleep. B. Allow the child to fall asleep with the television on. C. Remain uninvolved until the child awakens D. Schedule professional counseling for the child 4. A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider? A. Weak pedal pulse distal to the site. B. Bilateral cool extremities C. Serum glucose 90 mg/DL D. Blood pressure 102/58 mm Hg 5. A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings in the priority? A. The child swallows frequently B. The child refuses clear liquids C. The child’s throat pain increases D. The child cries often 6. A nurse is planning care for an 8 month-old infant who has bronchitis. Which of the following actions the nurse include in the plan of care? A. Use a bulb syringe to suction the nares. B. Place the infant in a room with negative-pressure airflow. C. Administer a meningococcal vaccine upon admission D. Initiate IV antibiotic therapy. 7. **A nurse is preparing a parent's’ education class about nutrition for toddlers. The nurse should identify which of the following findings as an indication of protein deficiency? A. Dry, thinning hair B. Muscle twitching C. Dental caries D. Poor skin turgor8. A nurse is caring for a 10 month-old child who was brought to the ED by his parents following a head injury. Which of the following actions should the nurse take first? A. Examine the scalp for lacerations. B. Inspect for fluid leaking from the ears. C. Assess respiratory status D. Check pupil reactions 9. A nurse is collecting data from a toddler who weighs 20 kg (44lb) and has a full-thickness burn to 10% of his body.Which of the following findings should the nurse report to the provider? A. Bowel sounds 20/min B. Increased restlessness C. Resp. rate 25/min D. Urinary output 35 mL/hr 10. A nurse is an ED is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect. A. Jaundice B. Hyperpyrexia C. Polyuria D. Neck vein distention 11. A nurse is assessing a preschool-age child who has celiac disease. Which of the following finds should the nurse expect? A. Obesity B. Polyphagia C. Steatorrhea D. Chronic constipation 12. A school nurse is assessing a 7 y/o student. The nurse should identify which of the following findings as a potential indicator of physical abuse? A. Bruising around the wrists B. Front deciduous teeth missing C. Abrasions on the knees D. Weight in 45th percentile 13.** A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care? A. Provide a high-calorie, low-protein diet B. Encourage frequent physical activity to increase bone mass. C. Initiate contact precautions for the child D. Maintain a patent intravenous catheter. 14. A nurse is reviewing the laboratory results of a preschool-age who has hematuria. Which of the following results should the nurse report to the provider? A. Platelet count 170,000/mm3 B. Hgb 12 g/dL C. Hematocrit 36% D. BUN 21 mg/dL 15. A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?A. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections. B. Provide a pacifier coated with an oral sucrose solution prior to the injections. C. Inject the immunizations into the deltoid muscle. D. Use a 20-gauge needle for the injections. 16. A nurse is conducting a well-child visit with the parents of a 2 week-old newborn. The nurse should inform the parents that their NB should receive the measles, mumps, and rubella (MMR) immunization at what age? A. 12 months B. 9 months C. 4 months D. 6 months 17. A nurse is admitting a school-age child who has osteomyelitis, Which of the following actions should the nurse take first? A. Administer antibiotics B. Teach the child nonpharmacological pain management techniques. C. Request a referral for physical therapy D. Obtain a blood culture 18. A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube. Which of the following actions should the nurse take first? A. Check the pH of the gastric secretions. B. Flush the tube with water C. Set the administration rate on the feeding pump D. Attach the feeding bag tubing to the end of the NG tube 19. A nurse is caring for a 3 y/o who is recovering from surgery. Which of the following methods should the nurse use to assess the child’s pain level? A. Visual analog scale B. Oucher scale C. Poker chip tool D. Word-graphic rating scale 20. A nurse is caring for a 4 y/o child who has meningitis and is receiving gentamicin. Which of the following lab values should the nurse report to the provider? A. BUN 6 mg/dL B. Creatinine 1.4 mg/dL C. Creatinine 0.3 mg/dL D. BUN 12 mg/dL 21. A nurse is providing education to a parent of toddler who is experiencing sickle cell crisis. Which of the following statements by the parent indicates an understanding of the teaching? A. I should avoid massaging affected area B. I should expect my child to have an altered mental status C. I will apply cold compresses to painful areas D. I will increase my child’s fluid intake 22.** A nurse is caring for a child who has epiglottitis due to an infection with Haemophilus influenzae type B. Which of the following actions should the nurse take? Select all that apply:A. Initiate IV access B. Obtain a throat culture C. Inspect the epiglottis D. Begin droplet precautions E. Monitor oxygen saturation 23. A nurse is teaching home care to the parents of a preschool-age child who has heart failure. Which of the following information should the nurse include in the teaching? A. Withhold digoxin if the child’s pulse is greater than 100/min B. Provide for periods of rest C. Increases the child’s oxygen flow rate until the child no longer has cyanosis D. Weigh the child once each month 24. A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care? A. Offer sips of water 4 hr following surgery B. Maintain the head of the bed at a 30 degree angle C. Assist the adolescent to ambulate 12 hr following surgery D. Ensure two nurses logroll the adolescent every 2 hour 25. A nurse is providing teaching to a parent of an 11 month old infant who has acute diarrhea and dehydration. Which of the following fluid should the nurse instruct the parent to provide to the infant? A. Glucose water B. Chicken broth C. Half-strength apple juice D. Oral electrolyte solution 26. A charge nurse is teaching a group of nurse about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse? A. A mother is hesitant to comfort her 6 month-old infant B. An 8 month old infant cries when his parent leaves the room C. A toddler has bruises on his knees D. A toddler repeatedly refuses to let a nurse auscultate his lungs 27. A nurse is reviewing the medical record of a 6 month old infant who has heart failure prior to administering medications. The nurse should recongize that which of the following medications is contraindicated? (click on the “exhibit” button) A. Furosemide B. Digoxin C. Sprionolcatone D. Enalapril 28. A nurse is assessing a 24 month old toddler. Which of the following findings should the nurse report to the provider? A. Holds his breath when having a temper tantrum B. Sleeps 11-12 hr per day C. Has a vocabulary of 30 words D. Eats a large amt of food one day than very little the next29. A nurse is helping a school-age child who has celiac disease select menu items for the next day’s meals & snacks. Which of the following foods should the nurse encourage the client to choose? A. A cheese omelet with OJ B. Graham crackers with peanut butter C. Beef, barley and vegetable soup D. Sliced chicken breast on whole wheat bread 30. A nurse is providing discharge teaching to the parents of a preschool age child who has heart failure and a new prescription for digoxin oral solution. Which of the following instructions should the nurse include? A. Rinse your child’s mouth with water after giving the medication B. Mix the medication with 6 oz of your child’s favorite juice C. If your child vomits, do not give the medication for 48 hours D. If a dose is missed, double the next dose 31. A nurse is providing teaching to the parents of a child who had varicella about management of the disease. Which of the following instructions should the nurse include in the teaching? A. Avoid giving the child a bath while vesicles are present B. Keep the child away from others until the skin is clear of scabs C. Apply calamine lotion to vesicles on the child’s skin D. Dress the child in warm clothing to promote healing of vesicles 32. A nurse is teaching an adolescent who has a methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the adolescent indicates an understanding of the teaching? A. I can continue to participate in wrestling matches B. I will use a new razor each time I shave C. I will soak in a warm bath every evening D. I will wash the infected area first when I shower 33. A nurse in an ED is caring for a child who experienced a submersion injury. Which of the following is the priority action for the nurse to take? A. Assist with intubation B. Obtain an ABG sample C. Administer an IV bolus D. Apply warming blankets. 34. A nurse is administering an opioid to an adolescent who is in sickle cell crisis. Which statement is true regarding opioid pain management? A. Oral opioid doses should be larger than parenteral doses. B. Oral opioids should not be combined with other types of pain relievers C. Opioid doses should be used for mild pain D. Opioid doses should be treated until sedation occurs. 35. A nurse is providing teaching to the parents of a school-age child who has ADHD. Which of the following should the nurse include? A. Place the child’s daily activities on an organizational chart. B. Instruct the child to study challenging subjects in the afternoon C. Administer the child’s medication at bedtimeD. Have the child do homework with siblings 36. A nurse in the emergency department is caring for an adolescent who is requesting testing for STIs. Which of the following actions is appropriate for the nurse to take? Request for verbal consent from the social worker Obtain written consent from the client Postpone testing until the client’s parents are present Contact the client’s parents to obtain phone consent. 37. A nurse is providing in discharge teaching to the parents of school age child following placement of ventriculoperitoneal shunt. The nurse should determine that the teaching was effective when the parents identify which of the following as an indicator the shunt has been displaced? Hyperactive bowel sounds Decreased urine output Elevated temperature Increased sleeping 38. A nurse is planning care for a child immediately following the insertion of a chest tube for continuous suction with a closed drainage system. Which of the following interventions should the nurse include in the plan of care? Ensure continuous bubbling present in the suction control chamber Record the amount of chest tube drainage every 2 hours Change the chest tube insertion site dressing every 12 hours Report the presence of tidaling of fluid in the water seal chamber 39. A nurse is providing teaching to a parent of an infant who has diaper rash. Which of the following statements by the parent indicates an understanding of the teaching? I will keep the area warm and moist I will sprinkle talcum powder over the affected area twice daily I will use antibacterial soap to wash the rash with each diaper change I will use super-absorbent disposable diapers 40. A nurse is assessing a child who is 2 hour post-operative following cardiac catherization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first? Monitor pulse distal to the insertion siteAdminister acetaminophen Apply pressure just above the insertion site Check the child’s blood glucose level 41. A nurse is providing dietary teaching to a parent of a 10-month-old infant who has phenylketonuria. Which of the following responses by the parent indicates an understanding of the teaching? I will steam carrots and cut them into small pieces for her My daughter can’t drink orange juice I will switch her to whole milk now that she’s old enough I should ensure that my daughter eats 1 ounce of meat every day 42. A nurse is providing teaching about medication administration to the parents of a toddler who has a new prescription for liquid ferrous sulfate. Which of the following instructions should the nurse include in the teaching? Report tarry, green stools to the provider Provide an antacid prior to administration Dilute the drops with water prior to administration Administer the drops with milk 43. A nurse is reviewing laboratory results of a school age child. Which of the following findings should the nurse report to the provider? Erythrocytes 4.5 million/mm^3 Platelets 110,000/mm^3 Hemoglobin 12 g/dL Leukocytes 10,000 cells/mm^3 44. A nurse in PACU is caring for a school age child immediately following tonsillectomy. Which of the following actions should the nurse take? Place the child in a side-lying position Instruct the child to drink fluids through a straw Encourage the child to deep breathe and cough Offer the child ice cream when alert 45. A nurse is caring for an infant who has heart failure and is receiving digoxin. Which of the following findings indicates a positive response to the medication?Urine output 2 mL/kg/hr Capillary refill 4 seconds Heart rate 187 min Respiratory rate 32/min 46. A nurse is caring for a child that has sickle cell anemia. Which of the following is the priority for the nurse to report to the provider? Facial twitching Constipation Enuresis Kyphosis 47. A nurse is caring for a child who is 2 days postoperative following an appendectomy due to rupture of the appendix. The child’s NG tube is set to low intermittent suction. Which of the following findings indicate that the child’s gastrointestinal function has returned? The abdomen is soft and nondistended on palpation The NG tube has 20 mL of output every hour The nurse auscultates bowel sounds The child reports thirst and hunger 48. A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching? You should consume flavored yogurt instead of plain yogurt You can drink milk on a empty stomach You can replace milk with nondairy sources of calcium You may tolerate plain milk better than chocolate milk 49. A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling. Which of the following reactions is an age-appropriate response to death? The child can give a logical explanation for the sibling’s death The child feels responsible for the sibling’s death The child is curious about what happened to the sibling’s body The child views the sibling’s death as permanent50. A nurse is caring for a toddler who is postoperative following cleft palate repair. Which of the following actions should the nurse take? Keep the toddler NPO for 24 hours postoperative Use a bulb syringe to suction oral secretions Change oral packing every 6 hours Administer opioids for mouth pain 51. A nurse is reviewing the results of the newborn screening for a newborn who is 1 week old. Results include total T4 0.8 mcg/dL, phenylalanine 0.7 mg/dL, and negative galactosemia. Which of the following interventions should the nurse include in the plan of care? Monitor the newborn’s urine for ketones Instruct the newborn’s parent about how to administer levothyroxine Initiate a diet low in phenylalanine Obtain blood glucose levels every 4 hour 52. A nurse is caring for a 4-year-old child who has moderate dehydration. Which of the following findings should the nurse expect? Weight gain Heart rate 70/min Orthostatic hypotension Respiratory rate 18/min 53. A nurse is caring for a school age child who is in 90 degree/90 degree skeletal traction. Which of the following actions should the nurse take? Ensure that the pulley mechanism is attached to the skin Release the traction to allow the child to bathe Adjust the weights to allow the child to turn Place the child on an alternating pressure mattress 54. A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect? (Select all that apply) Crying Fever RestlessnessEnlarged sub clavicular lymph node Increased appetite 55. A nurse is assessing a 6-month old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider. Pharyngitis Rhinorrhea Tachypnea Coughing 56. A nurse is providing teaching to the parents of a child who is receiving radiation therapy. Which of the following instructions should the nurse include in the teaching? (Select all that apply) Avoid giving your child lengthy baths Encourage mild activity daily Offer a diet rich in fresh fruits and vegetables Apply an oil based lotion over the irradiated area twice per day Dress your child in loose-fitting clothes 57. A nurse in an emergency department is assessing and adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect? Hyperactive reflexes Ataxia Pinpoint pupils Hypothermia 58. A nurse is caring for a newly admitted toddler who has acute diarrhea. Which of the following actions should the nurse take first? Initiate contact precautions Obtain a stool specimen for culture Administer an antibiotic Give 0.9% sodium chloride IV bolus 59. A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots? Cheeks60. A nurse is caring for a child who is to receive the first dose of IV gentamicin. Which of the following actions should the nurse take? Initiate airborne precautions Monitor for constipation Maintain strict I&O Encourage the bed rest 61. A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include teaching? “We will measure the amount of protein in your baby’s urine over a 24 hour period.” “Your baby will need to fast for 8 hours prior to the test.” “A nurse will insert an IV prior to the test.” “The test will measure the amount of chloride in your baby’s sweat.” 62. A nurse in prioritizing care for four clients. Which of the following clients should the nurse assess first? An adolescent who has sickle cell anemia and slurred speech An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10 A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin A toddler who has a partial-thickness burn on his right hand and requires a dressing change 63. A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new prescription for dornase alfa. Which of the following instructions should the nurse include the teaching? “Store the medication in the refrigerator.” “Use a spacer with this medication.” “Administer every 4 hours as needed for cough.” “Mix the medication with albuterol solution prior to administration.”64. A nurse is caring for a child who has bacterial meningitis. Which of the following criteria indicates the nurse should remove the child from droplet precautions? Absent nuchal rigidity Negative cerebrospinal fluid culture Temperature below 37.4 degree Celsius (99.4 F) Antibiotics initiated 24 hr ago 65. A nurse is assessing a school age child who has type 1 DM. The nurse notes that the child is diaphoretic. Which of the following actions should the nurse take? Obtain a blood glucose level Administer 1 unit of regular insulin Give 500 mL 0.9% sodium chloride IV bolus Check urinary ketones 66. A nurse is caring for a child who is terminally ill. The parents tell the nurse that their child is going to be fine because they heard about another child who survived the same illness. Which of the following responses should the nurse make? “The provider told you that your child’s illness is terminal.” “Let’s talk about some happy memories with your child.” “Tell me what you know about your child’s illness.” “It is important that you believe your child will survive.” 67. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect? Rhinorrhea Steatorrhea Weight gain Visible peristalsis 68. A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching? Soak hairbrushes in boiling water for 10 minutes Apply bactericidal ointment to lesionsAdminister acyclovir PO two times per day Seal soft toys in a plastic bag for 14 days 69. A nurse is preparing to administer naproxen 150 mg PO to a child who is experiencing pain. Available is naproxen 125 mg/ 5 ml solution. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 6 ml 70. A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer? Hepatitis B Varicella Haemophilus influenzae type B Rotavirus